Making Space for Emergency Talk

By Dr Lucio Naccarella, University of Melbourne, and Associate Professor Bernice Redley, Deakin University

Hospital emergency departments are high-pressure environments where the stakes are high – often life or death. These spaces have historically and overwhelmingly been designed to fast-track patients through to treatment areas.

But where do nurses or doctors go to consult privately or debrief amid the stress?

They can’t go to the cafeteria, it is too far away, and they can’t disappear into offices because their work demands that they be able to see and be seen in order to respond quickly to fast-moving events. Instead critical conversations about patient care and staff welfare are being hurriedly whispered in corridors or behind partially drawn curtains, or even inside crowded storerooms.

It is a recipe for unnecessary stress, miscommunication and, ultimately, mistakes. Previous research suggests that miscommunication between hospital staff is the root cause of up to a staggering 80 per cent of medical errors.

Our new Emergency Talksstudy, which included a survey of over 100 emergency care workers and follow up interviews with 39 of them, examined the influence of these workspaces on the vital informal staff communication that goes on in emergency departments. It reveals that staff are having to make some difficult trade-offs to accommodate their work practices and their need for privacy; whether that’s to discuss a patient or provide comfort to each other.

“A lot of communication is on the fly. When you are in the corridor, that’s the opportunity to talk to your buddy or a senior nurse going past,” one emergency nurse told us.

Others explained how difficult it was to have blunt and confidential conversations without patients overhearing. As one staffer reported “there is no privacy with a curtain, as much as you think there is. A few patients have commented on what we’ve said. They know everything that goes on.”

Our study suggests we need to provide staff with safe and confidential spaces to communicate effectively that don’t compromise their connection to patients and other staff. But, realistically, there just isn’t the space available in our already over-burdened emergency rooms.

The solution then is new types of small, adaptable and protected workspaces that staff can use for a variety of activities, including informal communication. It means greater use of multifunction glassed-in areas and low-height partitions where staff can find some temporary privacy amid the bustle around them.

High visibility, highly connected large open spaces such as nurses’ stations, staff hubs, and specialist care areas are ideal for staff safety and are the most likely places to be used for formal and informal talk about patients. But these spaces are often not suitable for sensitive conversations or staff debriefing.

One nurse told us that staff are resorting to going into storerooms and medication rooms to have private chats. “They are sealed up places…because sometimes these are just kind of vents…that’s where you can go (and) just hide between compactors.”

Corridors are also used frequently for informal communication, but are often not sufficiently private or considered safe by staff. Spaces far from patient areas such as the tearoom or cafeteria are inconvenient for impromptu discussions, but ideal for more general social interaction.

Staff often compromise their own physical comfort (such as not sitting down) in order to satisfy other more functional needs such as maintaining high visibility and staff numbers on the floor. “It is nice to sit and take a breath…there are steps in the medication room…instead of writing on the benches you can sit on the step in the medication room.”

Surprisingly we also found that staff didn’t support some of the current design trends toward “de-institutionalising” hospitals by making them more homely and less clinical looking. While such an approach may have merits in other parts of a hospital, emergency staff told us that the high-pressure environment of emergency departments demanded a hierarchical environment that afforded a level of control over patients and barriers that allow staff to exclude patients when necessary.

In their frenetic workplace, staff seek glass barriers, doors, curtains and alcoves to provide a measure of safety and separation, but are aware that these also effectively cuts them off from their patients. The task then is to find the right balance.

Small, multi-purpose spaces dedicated to non-patient activity are ideal and required for informal communication between staff. But such dedicated spaces are unlikely to be allocated in emergency departments because of tight space constraints, and if they are they can become cluttered with equipment. Instead designers need to focus on providing small, easily adaptable spaces that keep staff visually connected and acoustically separated, and can be used for a variety of activities.

DESIGN SOLUTIONS

Small, glazed spaces: These can provide visual connection to patients and other staff while allowing privacy from being overheard. By being small they are less likely to be used as adhoc storage spaces.

Sit and go booths: Small booths with chairs and a small table invite short but comfortable informal meetings. A low-height partition can protect occupants from interruption but still keep them connected to what is around them.

Standing desks: Stand-up furniture tells people that a space is transitory and conversational and provide an opportunity for the fast recording and transfer of patient information.

If we want to reduce mistakes and stress loads on hospital staff, then re-examining the design of our emergency departments is a good place to start. We need spaces that enhance staff perceptions of safety, control and visual connectedness, while at the same time addressing the aesthetics and physical comforts that improve the experiences of both workers and patients.

Emergency Talks was funded by international design practice HASSELL and an Australian Department of Industry Research Connections grant in a collaboration with the University of Melbourne’s Centre for Health Policy, and Deakin University’s Centre for Quality and Patient Safety, and Monash Health.

Acknowledgement: Michaela Sheahan from HASSELL contributed to the development of this article.